Screening for cancer of the Cervix

What is the cervix?

Why is Cancer cervix important? Cervix is the mouth of the uterus.

One out of every five women in the world suffering from this disease belongs to India. More than three-fourths of these patients are diagnosed at advanced stages leading to poor prospects of long-term survival and cure.

What, if any, is the silver lining in the matters of Cance rof cervix?

Cervix is an organ which is easily visible and also accessible during routine gynaecologic examination. Hence any abnormality of cervix holds the promise of easy detection and therefore early, appropriate intervention. This means that with regular screening, it is possible to keep a track of any undesirable change that a cervix might undergo.

What is screening for cervical cancer?

Screening is a method by which all the population- including the healthy ones are subjected to some test or examination so that it is possible to pick up the ones which are abnormal. Screening must not be confused with a diagnostic test. A screen merely detects a possible high risk case while a diagnostic test is used to confirm the presence or absence of the disease.Screening for cervical cancer aims at recognizing women who are at high risk of and likely to develop cancer of the cervix.

Who can get cancer of the cervix?

Any sexually active woman can get cancer of the cervix. However there are a few women.who are at a higher risk (probability) than others in getting cancer cervix.

Who are the high risk women for Cancer cervix?

The following factors are well recognized risk factors for cancer cervix:a) Early age of marriage and/or early age at first intercourse.b) Early age at first child birth. Multiple pregnancies.c) Sexual promiscuity: Multiple sexual partners or sexual partner with multiple partners.d) Persistent HPV (Human Papilloma Virus) Infectione) Co-exists with other sexually transmitted diseases like HIV, syphilis and gonorrhea.f) Smokersg)

Women receiving immune-suppressant drugsAre any women at lower risk?

Monogamous women whose sexual partners have had circumscision or have used condoms. (The male smegma has been implicated in the causation of cancer Cervix.) may be at a lower risk.Long term efficacy of vaccination against HPV for Cervical cancer prevention is being studied.Virgins, women who have not borne children may also be at lower risk.

What is the natural history and evolution of Cancer of the Cervix?

As we are aware, the cells in our body are in a state of constant flux. New cells keep replacing the old ones as a part of this remodeling mechanism. Due to certain reasons, the cells of the cervix gradually transform from being normal to cancerous. This transformation does not occur overnight or over a period of days. It takes several YEARS for a normal cervix to become cancerous.Before becoming obviously cancerous, the cervix therefore has a long pre-cancerous period. Sometimes, it may take well over 15-20 years for a pre-cancerous cervix to become overtly cancerous.Hence it is possible to detect an abnormal cervix during the course of its evolution from normal to abnormal. And therefore halt the process by appropriate interventions.

What does the screening for cervical cancer do?

Cervical cancer screening aims to pick up abnormal cells that are developing in the cervix. As mentioned earlier, cervix is one of the organs that is easily visible to the naked eye. Hence it is possible not only to visualize the cervix but also do certain simple tests on it in order to confirm or rule out the presence of an abnormality.

Who must undergo screening for Cancer of the cervix?

All women who are sexually active currently or have ever been, merit screening for cancer of the cervix.A concrete screening program and follow up to identify pre-cancerous cervices has not yet been strategized in India, unlike in the UK where the organized and well documented cancer screening program has seen a dramatic reduction in cases of cervical cancer.

What are the tests done for cervical cancer screening?

Inspection of the cervix: Visualizing the cervix under good light and after the application of acetic acid aids in identifying suspicious areas. Pap’s Smear: This is a simple test done quite extensively all over the world for early detection of cervical cancer.Colposcopic examination: Often undertaken after an abnormal Pap’s test. A colposcope is a specialized equipment which helps to examine the cervix under magnification and through filters. This gives information about the nature and degree of cervical abnormality. Colposcopes also aid while taking biopsies and doing certain operative procedures on the cervix.HPV DNA testing: Infection with certain strains of HPV (Human Papilloma Virus) predisposes to development of cancer cervix. HPV DNA testing aims to detect the presence of such infectious strains. This test is an advanced technique and is not routinely used universally because of the cost implications.

What is a Pap’s Test?

Pap’s Test or Pap’s smear (named after the Greek Doctor, George Papanicolaou, who invented the test) is a very simple yet indispensible test for the detection of an abnormal cervix. It has helped save the lives of millions of women all over the world.Cells from the cervix are collected and are either smeared on a slide or transferred on to a liquid in a test tube. These cells are then studied under the microscope by the pathologist/cytologist.When seen under the microscope, cells which are cancerous and those which are pre-cancerous (destined to turn into cancer in the future) appear very different from normal cells of the cervix. The cytologist then reports it as per International Guidelines which helps the treating doctor to do the needful.

How is a Pap’s test done?

A Pap’s smear entails a pelvic examination. The cervix is visualized completely under good light and its surface and canal are gently swept or brushed with the help of an Ayre’s spatula and/or Cyto-brush. As the cervix is insensitive to touch, the woman will have no pain at all. So getting a Pap’s smear is as simple or as uncomfortable as a pelvic examination!

Any precautions before undergoing a Pap smear?

A Pap smear cannot be done during menstrual flow. It is ideally done after a week after the last menstrual period, and before the onset of the next cycle.Vaginal infections interfere with the smear report or such a smear gets simply reported as inflammation. Hence, pre-existing infections must be satisfactorily dealt with before taking a Pap’s smear.Douching the vagina must be avoided at least 24-48 hours before the smear.It would also do well to abstain from sex for 24-48 hours before a smear.No antiseptic creams are used while taking a Pap’s smear.

What is an abnormal Pap’s Smear?

An Abnormal Pap’s Smear DOES NOT mean Cancer! There exists an Internationally agreed classification, grading and nomenclatures which helps the clinicians to chalk out further course of action. Depending on the report, a Pap’s smear is followed up with colposcopy and/or repeat Pap’s smear after a specified time and/or cervical biopsy. However an abnormal Pap’s smear needs regular follow up until the abnormality is resolved. The treating doctor will be able to discuss with you the significance of the smear report and the future course of action. BUT AN ABNORMAL PAP’S IS NOT CANCER.

When should Cervical cancer screening be initiated?

It is good practice to do the first Pap’s smear on a woman at the age of 25 if she is sexually active. HPV infection often interferes with interpretation of smear reports. However, HPV infection is common in women before the age of 25 and is also often self-limiting. Hence, the rationale in not doing a Pap’s test for women below 25 years even if they are sexually active.

How frequently must one undergo the Pap’s smear test?

Keeping the relatively slow evolution of cancer cervix in mind, it is proposed that if a Pap’s smear is reported as normal, then the woman will need a repeat testing only after three years. However an abnormal Pap’s is dealt with according to the nature of abnormality.

For how many years must a woman continue to get the Pap’s smear done?

As cancer of the cervix is the disease of the reproductive age group (upto 45 years) a normal Pap’s smear must be done every three years upto the age of 50. Also, as cancer of the cervix is a slowly evolving condition, it is proposed that for a woman beyond 50 years, repeating Pap’s once every five years upto the age of 65 is a safe practice. If all smears have been normal, then, after the age of 65, the incidence of cervical cancer is remote and hence screening may be closed. In conclusion: Cancer cervix is the commonest cancer in India and can affect any sexually active woman. By a simple screening test-the Pap’s smear, it is possible to detect pre-cancerous stage in the cervix. An abnormal Pap’s smear does not mean Cancer. It is a mere alert and indication for the treating doctor to carry on further tests and treatments. It is possible to ESCAPE from Cervical cancer by undergoing regular Pap’s smear testing!!